key: cord-0690868-tpm1l661
authors: Nonglait, Phibakordor L.; Naik, Raghuram; Raizada, Nishant
title: Hypophysitis after COVID-19 Infection
date: 2021-10-26
journal: Indian J Endocrinol Metab
DOI: 10.4103/ijem.ijem_329_21
sha: de863e1910f7ad8c92cbc801c8d6a3a029c6d88f
doc_id: 690868
cord_uid: tpm1l661

nan

A cross-sectional survey study was conducted at the endocrine department of SVP hospital, Ahmedabad. Sixty middle-aged patients meeting the inclusion criteria were screened for frailty with five items FRAIL questionnaire. [4] Middle-aged males and females aged between 49 and 65 years, diagnosed with diabetes by endocrine/medicine department for ≥4 years were included. Patients with other known causes of frailty and patients with severe mobility issues were excluded. Spearman's correlation was used to find the correlation.

There were 33 males, 27 females with mean age 56.3 ± 5.2 years, mean HbA1c was 7.9 ± 1.7%, years since disease (YSD) 7.3 ± 6.1 years, FRAIL score 3 ± 1.5. Thirty-seven (61.6%) subjects were found frail, 19 (31.6%) pre-frail, 4 (6.6%) healthy. Frailty was found to be highly correlated with the severity of diabetes (HbA1c) but showed no correlation with chronicity of diabetes and the BMI of the individuals. S. Chode's study found that prevalence of frailty was higher in middle-aged diabetics than non-diabetic middle-aged people and diabetics with high BMI were likely to be frail and were less physically active. Pathophysiology of diabetes is commonly focused on impaired insulin secretion, overload of gluconeogenesis, and insulin resistance; newer insights broaden this etiologic horizon. Immunologic factors that create a chronic state of low-grade inflammation -"inflammaging" -have an influence on both the aging process and diabetes. [5] Frailty is a dynamic process.

A person's frailty categorization may change depending on a change of circumstances such as hospitalization and recovery from an acute illness. Also, recovery from severe hypoglycemia or profound hyperglycemia may also result in improvement in frailty scores. Therefore, frailty scores need to be reviewed from time to time.

Frailty can be targeted for treatment; therefore, early identification of frailty is important. Overall fitness of diabetics is of utmost importance to decrease the impact or avoid diabetic complications. Early multimodal interventions based on physical exercise and nutrition education should be investigated and implemented with a prompt diagnosis of frailty. Future studies should aim at a detailed assessment of frailty in diabetics.

Nil.

There are no conflicts of interest.

Community Health and Rehabilitation, SBB College of Physiotherapy, Ahmedabad, Gujarat, India

Sir, We read with great interest the article by Kumar et al., [1] regarding endocrine dysfunction among patients with coronavirus disease-19 (COVID-19).

While there have been reports of pituitary involvement in COVID-19 in the form of pituitary apoplexy on the background of underlying adenoma, we recently came across a case with hypophysitis after COVID-19 infection. [2] A 27-year-old male patient presented with malaise, anorexia, and vomiting associated with early morning headaches since the past 4 weeks. He did not have fever, diplopia, pain abdomen or polyuria. He had been diagnosed as COVID-19 by reverse transcriptase-polymerase chain reaction (RT-PCR), 2 weeks prior to the onset of present symptoms. He had not received vaccination against COVID-19. He had mild symptoms at that time and was managed conservatively. He did not receive any glucocorticoids and did not require supplemental oxygen. His physical examination was unremarkable.

There was no postural hypotension or visual field defect. Laboratory evaluation revealed hyponatremia (120 meq/L), hypocortisolism (8 am cortisol <0.50 µg/dl) and hypothyroidism (TSH 3.07 µIU/ml and free T4 0.45 ng/dl, normal range of free T4:0.89-1.76 ng/dl). His serum testosterone and gonadotropins levels were also low. He had hyperprolactinemia (93.12 ng/ml, normal range 2.1-17.7 ng/dl). In view of the panhypopituitarism, MRI of sella was advised. MRI revealed a diffusely enlarged pituitary and thickened stalk with homogenous post-contrast enhancement [ Figure 1 ]. These findings were suggestive of hypophysitis.

A provisional diagnosis of lymphocytic hypophysitis, possibly related to COVID-19 was kept. He was initiated on therapeutic doses of steroids for hypophysitis and thyroxine replacement. He is currently under our follow-up.

The hypothalamus and pituitary are putative targets for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) due to angiotensin-converting enzyme2 (ACE2) expression. [3] Leow et al., [4] had reported post-infectious hypophysitis with transient hypocortisolism in patients who survived the previous severe acute respiratory syndrome (SARS) epidemic. Misgar et al. [5] recently reported a case of infundibuloneuro-hypophysitis which presented with central diabetes insipidus. However, there was no involvement of the anterior pituitary as demonstrated by normal hormonal in their patient.

We did not perform a pituitary biopsy to confirm our diagnosis and the causality with COVID-19 cannot be proven in our case.

However, the past history of COVID-19 in this patient and the propensity of SARS-CoV-2 to affect endocrine tissues makes this diagnosis a possibility.

In light of our experience, hypophysitis should figure in the list of differential diagnosis when patients with exposure to COVID-19 present with pituitary dysfunction.

Nil.

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